How to Document Exams Performed by Medical Students

Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: How should my medical students and I document examinations they perform?

ANSWER: As physicians, we can all relate to the need for medical students to obtain a history, perform an examination, present a case, and learn to document an accurate and succinct chart. The Centers for Medicare and Medicaid Services (CMS) recently updated its policy on medical students to read: “Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of [those items] in the medical record, rather than re-documenting this work.”

For clarity, it may also be helpful for teaching physicians to include an attestation such as, “This note, which I have verified, was prepared with the aid of a medical student. I personally performed the history, exam, and medical decision making.” See the ACEP Teaching Physician Guidelines FAQ and CMS Transmittal 3971 for further details.

Brought to you by the ACEP Coding and Nomenclature Committee.

Dr. Lemanski is associate professor of emergency medicine at the University of Massachusetts Medical School–Baystate in Worcester.